Words Matter

Words Matter

Understanding patient vicinity and patient space

If there is one thing I have learned while dealing with codes, it is that words do matter. A simple word like "shall" means something very different than the phrase "shall be permitted," a distinction that if missed often leads to confusion regarding implementation of a code.

One of the more prevalent misunderstandings I see is the interpretation of patient vicinity versus patient care space. Both include the word "patient," so they mean the same thing, right? Wrong. "Patient vicinity" is defined in NFPA 99: Health Care Facilities Code and reiterated by Art. 517.2 in NFPA 70: National Electric Code (NEC) as "a space, within a location intended for the examination and treatment of patients, extending 1.8 m (6ft) beyond the normal location of the patient bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extending vertically to

2.3 m (7ft, 6 in) above the floor." So, in simple terms, the patient vicinity is the area within the wingspan of the patient. This definition is intended not only for inpatient functions but also for outpatient services, and is not just limited to a hospital bed location.

In contrast, the patient care space has a much broader range of coverage. The NEC definitions for spaces are derived from the NFPA 99 definitions of "patient care rooms." NFPA 99 defines the general description of "patient care room" with the same words that 517.2 uses for "patient care space” as "space within a health care facility wherein patients are intended to be examined or treated.”

The patient care space encompasses the patient vicinity, but is not limited to the wingspan parameters of the vicinity definition. The article provides further information to clarify basic care spaces, general care spaces, critical care spaces, and support spaces. The categories of spaces define the range of risk to patients or caregivers from “not likely to cause injury" to "likely to cause major injury or death." NFPA 99 also provides Annex material, which is additional explanatory material regarding the space (room) criteria. (As a side note, I always pause when I read these definitions. Not every profession can say they make decisions based on a potential outcome of "major injury or death.")

Why does a clear understanding of patient vicinity and patient care space matter? Like everything else in the code, these terms are used in other sections to inform and implement additional criteria. Where the definition of patient care space and vicinity really affect the electrical design and construction of a facility is in the wiring requirements. Article 517.20 of the NEC indicates that the wiring and protection requirements of 517 apply to patient care spaces of all health care facilities. Article 517.13 further indicates that wiring in patient care areas shall comply with 517.13(A) and (B). Section (A) indicates the branch circuits serving the area "shall be provided with an effective ground fault current path by installation in a metal raceway system, or a cable having a metallic armor or sheath assembly." Section (B) requires an insulated equipment grounding conductor. This means that the entire defined patient care space (not just the vicinity) is required to have a redundant ground path. The intent of this requirement is to eliminate the opportunity for the patient to be the “ground path." (Another side note: NFPA is working on alignment between codes to eliminate the word “area” and instead use the word "space." Again, words matter.)

Even though the patient care space is defined in 517.2, the Code throws in grey area by adding informational note number 1 to the definition (which is not enforceable but is provided for additional clarity): "The governing body of the facility designates patient care space in accordance with the type of patient care anticipated and with the definitions of the area classification." NFPA 99 also includes similar verbiage requiring the governing body of the facility or its designee to designate specific patient care rooms, but the NFPA 99 requirement is within the main code text so this criterion is enforceable.

The informational note in NFPA 70 (and the Annex article in NFPA 99) does exclude business offices, corridors, lounges, day rooms, dining rooms, or similar areas as not being required to be classified as patient care spaces. Be mindful that some jurisdictions do require critical branch receptacles in corridors (which is above and beyond NFPA Code requirements and the FGI Guidelines) with the concept that in the case of a major catastrophe, patients might be brought into the corridor for care. A hospital is a defend-in-place facility, and during a tornado patients and staff should move to an interior space and away from windows. With this particular interpretation, the corridor would become a patient care space and the determination would be in direct contrast to the informational note that a corridor is not a patient care space.

After all of the code verbiage has been evaluated and regurgitated, the owner's preferences and the engineer's opinions are what define the installation criteria for a particular project. When working with a facility to define or enhance the requirements for health care wiring in and around a "patient care space,” as the engineer, I consider the type of facility that is being designed or remodeled. Any amount of experience in a health facility or with health care design or installation will demonstrate that the areas of a health care facility are often fluid and subject to remodeling.

Using both health care and non-health care wiring as strictly defined by the code verbiage concurrently in the same space limits the ease of remolding and repurposing existing infrastructure. If the project scope is a complete renovation and replacement of existing conditions, then wiring isn't as significant an issue because everything will be demolished and removed. If the scope is to add a patient toilet or an exam room within an existing space previously not identified as "patient care,” then wiring will need to be replaced, or the facility will risk ending up with a non-compliant installation. This error often occurs when a small project is implemented by an entity that does not have health care expertise. For large projects with a significant scope of work, the upcharge for the health care wiring isn't usually significant compared to the time required to map out what is and is not defined by the governing body of the facility as a health care space. By maintaining consistent health care wiring standards within a designated space, confusion can be avoided during the original installation, and there will be additional flexibility for future changes. Wiring methodology should be a discussion point among team members to ensure compliance with the code, maintenance of the facility, and sensitivity to the project budget.

One last thing to remember is that the items in the Code book are minimum requirements to protect health and life safety. They do not necessarily include the requirements from the engineer in his/her specifications or any additional requirements from the authority having jurisdiction that may be more stringent.

This article originally appeared in the Fall 2015 edition of Inside ASHE, copyright American Society for Healthcare Engineering 2015.

TAGS: Design
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